Basic Medical Insurance For Urban Workers In Hohhot Municipal Implementation Method

Original Language Title: 呼和浩特市城镇职工基本医疗保险市级统筹实施办法

Read the untranslated law here: http://www.chinalaw.gov.cn/article/fgkd/xfg/dfzfgz/201111/20111100353018.shtml

Basic medical insurance for urban workers in Hohhot municipal implementation method

    (March 25, 2011 the Hohhot municipal people's Government at the 35th Executive meeting April 11, 2011 Hohhot municipal people's Government released 1th come into force July 1, 2011) Chapter I General provisions

    First in order to improve the level of basic medical insurance for urban workers, enhance the anti-risk ability of urban employee basic medical insurance fund, to further raise the level of medical insurance benefits, insured persons for medical treatment, according to the People's Republic of China Law on social insurance and related laws and regulations, based on actual city, these measures are formulated.

    II municipal co-ordinating principle of basic medical insurance for urban employees:

    (A) the urban workers ' basic medical insurance funding criteria and level of protection commensurate with the level of economic and social development; (B) implement the city-level overall plan of urban workers ' basic medical insurance, city and County unified criteria for levying charges, unified level of insurance benefits, the unified handling processes, unified messaging system.

    Medical insurance fund, at the same level and County management and responsibility-sharing;

    (C) adhere to basic medical insurance premiums borne by employers and individuals, and to receive, the principle of balance; insist on applying the principle of combination of social pooling and individual accounts.

    Thirdly, civil servants in participating in basic medical insurance based on access to Medicaid policy. Insured enterprises on the basis of the basic medical insurance, you can set up enterprise supplementary medical insurance for employees. Supplementary medical insurance premium in wages is less than 4% part of the expenses from the employee benefits expenses, inadequate welfare expenditures part, after approval by the financial departments included in the cost.

    Supplementary medical insurance funds by insurance companies on their own management.

    Article fourth while participating in basic medical insurance for urban workers, should take part in large medical insurance.

    Fifth article of the regulation is applicable within the administrative area of the city all employers and workers, as well as flexible employment, specific scope is as follows:

    (A) all types of enterprises (including the registration of town and township enterprises operating) and their employees;

    (B) the State organs, institutions, social organizations and trade unions;

    (C) private non-enterprise units and their staff;

    (D) operators of individual economic organizations and their employees;

    (E) the labor contract with the employer of migrant workers;

    (F) flexible employment personnel;

    (G) the laws and regulations of the other units and personnel.

    Enterprises in the city, the autonomous region is enterprise and Hohhot railway Bureau and other units and their employees in accordance with the principle of territorial management, unified basic medical insurance for urban employees participate in this city. Sixth city and County human resources and Social Security Department is the Department of medical insurance.

    City and county health insurance agency has specific responsibility for medical insurance work within their respective jurisdictions.

    Development and reform, finance, health, food and drug supervision, auditing, industrial and commercial departments, according to their respective functions coordinate the implementation of these measures.

    Chapter II basic medical insurance fund

    Seventh an employer shall provide basic medical insurance medical insurance agency management insurance formalities, while providing business license or approved the establishment of documents, organization code certificate, bank accounts, insurance personnel register and electronic documents.

    Insurance units to terminate the basic medical insurance or medical insurance registration changes, shall be terminated or changed within 30 working days from the date the insurance medical insurance agency for cancellation or change procedures. Article basic medical insurance premiums base pay authorized on an annual basis and not adjusted within one year.

    Insured persons for the first time in my last month's salary as the base to pay basic medical insurance premiums. Article basic medical insurance premiums paid by employer and employee both, individual insured persons, such as flexible employment, basic medical insurance premiums paid by the insured person.

    On the workers ' annual wage income is less than the city's annual average wage of fully employed staff on 80%, the city's annual average wage of fully employed staff on 80% as a base above the city above the annual average wage of fully employed staff on 300%, not as a base.

    (A) the insured more than the annual salary of all employees is the base, press 6% to pay basic medical insurance premiums.

    (B) the annual salary of the insured person to himself as the base, press 2% to pay basic medical insurance, withheld from the wages paid by his employer.

    (C) the individual insured persons with an annual average wage of fully employed staff on the city of 80% to 300% as the base, according to the employers and manpower planning and 8% of the standard pay of workers basic medical insurance premiums or you can pay at the hospital Coordinator for the 4.5% standard basic medical insurance premiums.

    With economic development and income increase, approved by the municipal people's Government, and collecting basic medical insurance rates may be adjusted accordingly.

    Article basic medical insurance premiums shall be paid before the 15th of the month, or quarterly, annual withholding.

    11th insured enterprises declared bankrupt according to law, priority shall be debts due to the basic medical insurance premiums paid, and at the time of liquidation of assets to the city's annual average wage of fully employed staff on base 80%, in accordance with the regulations for workers leave a year of basic medical insurance premiums. 12th basic medical insurance fund, "municipal planning, management, planning and control, quota transfer" management approach.

    Basic medical insurance for urban workers, and large health insurance and Medicaid funding for graded management of income and expenditure of the civil service. Article 13th funds adjustment funds of basic medical insurance system for urban employees. Adjustment funds by County annual basic medical insurance premiums collection tasks on 5% extract, extract levels according to 2%. City-level adjustment funds the balance of the calendar year to reach this year's collection of 15% of the revenue of the Fund suspended extraction.

    Adjustment funds could not be detached and year-end evaluation one-vote veto system. 14th adjustment funds in the city's area co-ordination insufficient funds payments, when there is a gap transfer, and upholding the principle of risk of this effort combined with local responsibility.

    Overall funding gap by local fund to solve the balance of the calendar year, shortfalls and then solved by adjustment funds. 15th medical insurance agency is responsible for the management of transfer payments, internal auditing system, adjustment funds announced payments on a regular basis.

    Adjustment funds into special financial account management, establish accounts alone, earmarks.

    16th basic medical insurance premiums not relief, no unit or individual may, on any grounds to refuse to pay taxes or pay less.

    Chapter III basic medical insurance benefits

    Article 17th personnel participating in basic medical insurance for urban employees reached the national statutory retirement age, period of contributions following the prescribed number, stopped paying the basic medical insurance premiums:

    (A) the insured person before December 31, 2004, continuous period of contributions is not less than 12 years.

    (B) from January 1, 2005 to November 30, 2009, insured persons, payment not less than 15 years in a row.

    (C) the insured person after December 1, 2009, continuous period of contributions is not less than 20 years.

    Article 18th retirement procedures for insured persons and their actual years of continuous contribution does not meet the minimum period of contributions provided for in article 17th of this approach, according to the following standards paid up the remaining years of basic medical insurance premiums:

    (A) the unit insured retirement, to the city's annual average wage of fully employed staff on base 80%, 6% once paid in full by the insurance unit by more than ten years of basic medical insurance premiums.

    (B) the insured individual retirement, to the city's annual average wage of fully employed staff on base 80%, 6% I once paid the remaining years of basic medical insurance premiums. (C) one-time payment difficulties of individual insured persons can be employed to pay standard yearly fees, enjoy retiree insurance benefits.

    Paid in full after the remaining term, no longer pay. Article 19th and former labor relations of the insured persons shall, within 6 months after the termination of labor relations for the health insurance continuation procedures, its insurance payment years continuous computing. Fails to go through, as a re-insurance.

    Re-insurance payment years before consolidation. 20th first of the urban workers ' basic medical insurance of employees, individual insurance and re-insurance personnel, set up a 6-month waiting period. Since the date of insurance or re-insurance, payment 6 months in a row before they can enjoy basic medical insurance benefits.

    Waiting period divided into personal accounts.

    Personnel flow within the city limits of insured employment, and no waiting period, payment years combined.

    21st basic medical insurance funds pay standard pay ceiling, pay scale and the specific criteria are as follows:

    (A) insured persons in designated medical institutions within a year fund to pay for hospital treatment for the first time and manpower standards: tertiary hospital for 500 Yuan, grade b hospital for 300 yuan, second class and below the hospital for 150 Yuan; secondary standard of pay in-patient treatment 30%, no payment for third and subsequent hospitalization of standards. (B) the basic medical insurance fund annual medical expenses must be paid within a maximum of 190,000 yuan. Individual burden consistent with the provisions related to large medical insurance reimbursed by the large proportion of supplementary medical insurance once again in accordance with the regulations.
Large medical insurance fund an annual maximum limit of 120,000 yuan.

    (C) funds paid over standard maximum payment limit, in line with the policy provisions of the section, as listed in the following table is paid, with the remainder paid by the insured individual.
┌──────────┬────────────┬────────────┐
│ │ Service │ managed fund proportion of retirees and manpower Fund │
│    住院医疗费用    ├───┬───┬────┼───┬───┬────┤
│ │ C │ c │ b │ c │ c │ b │
├──────────┼───┼───┼────┼───┼───┼────┤
Pay above-20000 │ │ 88% │ │ 92% │ │ 89% │ │ 93% │
├──────────┼───┼───┼────┼───┼───┼────┤
│ Above 20001-50000 │ 90% │ │ 95% │ │ 91% │ │ 95% │
├──────────┼───┼───┼────┼───┼───┼────┤
│ 50001 or more │ 95% │ │ 98% │ │ 96% │ │ 98% │

└──────────┴───┴───┴────┴───┴───┴────┘

    Basic medical insurance funds pay standards, pay scale, the highest limit, vary with the average wage of workers and fund balances be adjusted accordingly.

    Insured hospital treatment during the 22nd article, by your doctor using the drugs listed in the catalogue of class b drugs and pay part of the costs of basic medical insurance diagnosis and treatment projects, upon approval by the insurance medical insurance agency, the cost of which I pay 10%, coordinated by the health insurance fund and the remainder paid proportion of individuals in accordance with the regulations. Insured persons during the rescue, according to doctor's orders first use of blood products, protein products, but that it should be used within 5 working days after the approved insurance medical insurance agencies go through the formalities.

    The expenses paid by the individual 20% and the rest paid by the solidarity fund and the proportion of individuals in accordance with the regulations. One-time special implementation of price management of medical materials. Insured in-patient treatment during the use of the one-time special medical materials and their expenses paid by the individual 10% and the rest paid by the solidarity fund and the proportion of individuals in accordance with the regulations.

    Cost more than 3000 Yuan, should be approved by the insurance medical insurance agency.

    Article 23rd insured person due to technical constraints, equipment condition, diagnosis is unknown or there is difficulty in treatment required hospitalization is transferred to the other designated medical institutions in the city, the original referral advice given by medical institutions, medical expenses that occur before and after referral by a hospital stay costs. Insured persons by hospitals in Inner Mongolia, Inner Mongolia Medical College the first affiliated hospital of Mongolia and Inner Mongolia Hospital of medical technology, device constraints, unclear diagnosis or treatment is difficult to turn to the field hospital, by the above referral advice given by medical institutions, insurance medical insurance agencies approved transfer to provincial and municipal levels above basic Medicare hospital inpatient treatment. Meet the basic medical insurance fund to pay medical expenses, health insurance card, calendar, social security card, transfer form, medical records, expense summary details, diagnosis certificates, medical expense statement to the insurance medical insurance agencies approved claims.

    Basic medical insurance fund in the 21st paragraph (c) on the basis of 10%. 24th long-term offsite living retirees and insured branches abroad in more than a year of insured persons, of which I am selecting two local appointed medical institutions of different levels of basic medical insurance and insurance medical insurance filings. Medical expenses incurred, related documents to insured medical reimbursement formalities insurance agency. , Hospital, in-patient medical expenses paid in accordance with this standard.

    Needs of hospitals, medical expenses reimbursement in accordance with standard field hospital standards. 25th persons insured business trip or to visit relatives during the acutely ill, should be to the public hospitals above the county level, Parties shall present relevant documents to insured medical reimbursement formalities insurance agency.

    Medical expenses reimbursement standards in accordance with the field hospital standards.

    26th the insurance units and owed to basic medical insurance premiums paid by insured persons, suspended from the month of arrears covered by basic medical insurance treatment and divided into personal accounts; units insured and insured persons pay within 3 months, resume from pay month enjoy basic medical insurance benefits, and personal accounts.

    Arrears of over 3 months up to 6 months of age, insured and insured persons required to pay owed fees, and personal accounts, payment years continuous computing, arrears during the Fund does not pay for medical expenses and manpower.

    Fourth chapter of personal accounts and funds 27th the urban workers ' basic medical insurance funds and personal accounts pose.

    Pooling Fund and individual accounts separately, must not occupy, specific methods are as follows:

    (A) in accordance with the Commission accounts unit of combined insurance insured persons, who paid into all the basic medical insurance individual account; insurance unit to pay basic medical insurance is divided into two parts, the part used to establish a solidarity fund, part proportional to the provisions included in the personal account.

    (B) according to manpower planning and individual insured persons insured, its basic medical insurance premiums paid by except in accordance with the provisions included in the individual accounts, the rest into the solidarity fund.

    (C) in accordance with the individual insured persons insured hospital and Manpower, into all of their basic medical insurance premiums paid by the funds does not have a personal account.

    28th funds mainly to pay for insurance of hospitalization or emergency medical costs and medical expenses and outpatient and manpower approved special chronic disease outpatient costs.

    Urban workers ' basic medical insurance treatment, examination and treatment to strictly enforce the State and the autonomous communities of the list of drugs and the diagnosis and treatment projects list and the scope and amount on medical service facilities, beyond the "three directory" under the Fund does not pay for medical expenses and manpower.

    Article 29th according to manpower planning and insurance personnel, determined according to the different age into personal accounts, specific criteria are as follows:

    (A) the insurance companies pay into individual accounts, at the age of 45 years of age (45 years old), my wage income of the previous year as the base, according to 1% of the personal accounts; aged over 45 years old to retire in my income as the base of the previous year, according to 1.2% of the personal accounts.

    (Ii) select Commission account combined of individual parameter insurance personnel according to actual payment amounts, to above units payment designated into personal account proportion and workers personal payment account proportion of and, age in 45 age following (containing 45 age) of, directly by 3% of proportion designated into personal account; age in 45 age above to retired of, directly by 3.2% of proportion designated into personal account.

    (C) the annual pension or a pension for retirees on my base, according to 3.4% of the personal accounts.

    These standards according to the chronological age of insured workers automatically adjusts the proportion of individual accounts.

    Article 30th account cover mainly:

    (A) fixed-point medical institutions of outpatient medical costs and outpatient prescription distribution point outside retail pharmacy drug purchase cost of drugs;

    (B) funds to pay medical expenses below the standard;

    (C) the standard of paying funds over maximum limit by the burden of medical costs;

    (D) the overall maximum limit above the medical expenses of the Fund;

    (E) the laws, regulations and other costs.

    31st the following range of medical expenses not covered by the basic medical insurance fund:

    (A) shall be paid from the work injury insurance and maternity insurance fund;

    (B) shall be borne by the third party;

    (C) treatment of emergent public health events organized by the Government;

    (D) overseas for medical treatment (including Hong Kong and Macao regions).

    32nd basic medical insurance fund for bank interest calculation is as follows:

    (A) when raising the basic medical insurance fund in accordance with the current deposit interest rates;

    (B) carry-over of funds and interest group for the last year, according to the 3-month lump-sum bank deposits carry interest at a rate;

    (C) deposit financial account accumulated funds, compared with 3-year installment savings deposits carry interest at a rate not below the grade level of interest rates.

    Article 33rd insured principal and interest of the staff personal accounts owned by individuals, can be carried forward for use, and inherited according to law.

    Article 34th medical insurance agencies at all levels should establish and improve the basic medical insurance fund, large health insurance fund budget and Medicaid funding system and civil service, accounting, Fund cost overruns early warning reporting system and internal control system.

    Basic medical insurance funds and personal accounts by the medical insurance insurance agency management, included in the financial account, the implementation of two lines of income and expenditure, earmarks, no unit or individual shall not be misappropriated.

    35th insured persons entitled to exercise supervision over operations of the basic medical insurance fund, also has the right to the insurance and health care insurance agency queries I personal accounts of revenue and expenditure of the funds. 36th medical insurance fund established monitoring mechanisms. Human resources and social security, and financial sector according to their duties, on medical insurance fund run situation for supervision management; audit sector to regularly on medical insurance handling institutions of Fund payments situation and management situation implementation supervision; sibling Government established by Government about sector representative, and employing units representative, and medical institutions representative, and unions representative and about experts participate in of medical insurance fund supervision Committee, master, and analysis medical insurance fund of payments, and management and investment operation situation,

    Comments and suggestions on medical insurance, carry out comprehensive supervision.
The fifth chapter special outpatient treatment of chronic disease management

    37th urban workers ' basic medical insurance for special diseases chronic disease outpatient treatment access.

    Insurance applications for treatment of specific chronic disease outpatient therapy, should meet the required range of diseases. Article 38th special diseases chronic disease outpatient treatment of basic medical insurance is divided into a, b two categories. For people with group a special application of chronic disease outpatient treatment of the insured person does not identified on a regular basis.

    B special applications for chronic disease outpatient treatment of the insured person the regular identification. 39th article parameter insurance personnel initial application special chronic diseases outpatient treatment treatment, must holding three level above basic medical insurance Sentinel Hospital of illness diagnosis, and records copies and the related check laboratory results, and by sentinel hospital practice industry physician fill in Hohhot city town workers basic medical insurance special chronic diseases outpatient treatment application table, by sentinel hospital Medicare section trial Hou reported parameter insurance to medical insurance handling institutions record.

    Insured persons also have two or more specific chronic diseases, to identify pay standards for their disease confirmed.

    40th medical insurance medical insurance agency after accepting the material claims for insurance staff, therapists should be organized to identify material unity of insured people to declare, to meet the conditions, issuing the Special manual for the outpatient treatment of chronic diseases.

    Has approval of specific chronic disease outpatient treatment of insured patients, no new declaration within two years. 41st group a particular chronic disease outpatient treatment and outpatient treatment of special chronic diseases according to disease b quotas for its management. B special chronic disease outpatient treatment of insured persons according to the confirmation of disease, outpatient payment standard or above, the maximum payment limit, and in accordance with the regulations of the Fund to pay.

    Special chronic disease outpatient costs of insured illness and hospitalization costs and medical expense for outpatient and manpower annual maximum limit for 190,000 yuan.

    Sixth chapter of basic medical insurance service management 42nd city level and county health care insurance agencies with a fixed-point units of qualifications and conditions of service on service, service content, service quality, and fees, as well as elements such as financial auditing and control signed a management services agreement, specifying the responsibilities, and in accordance with the management principles are settled directly with the fixed-point units for medical expenses and the costs of medicines.

    Medical expenses shall be paid from the funds, accounting by the fixed-point units; insurance settlement payment section and I fixed units.

    Article 43rd appointed medical institutions of insured persons can choose any doctor or designated medical institutions make up a prescription at any point outside the retail pharmacy to buy drugs.

    44th designated medical institutions and appointed retail drugstores should use social security project-building specifications and standard health insurance core platforms of computer management system of medical insurance.

    Article 45th County integrating existing health insurance information resources and Manpower, relies on "social security" and "social security project" implementation of standardized procedures, basic data development, data interface and function modules such as content, system interoperability, sharing of resources, implemented within the city limits the Agency direct link with medical care fixed-point medical institutions settled.

    The seventh chapter legal liability

    46th registration of an employer does not apply for medical insurance, rectification by human resources and Social Security Department; it fails to, employer health insurance premiums payable 1 time more than three times the amount of a fine, directly responsible to the charge and the other persons of less than 500 Yuan and 3000 Yuan fine.

    47th the employer fails to pay health insurance premiums, by human resources and Social Security Department ordered to pay or make up, and from the date of default of payment, plus five out of 10,000 late fee on a daily basis; still fails to pay the past due, default of payment 1 time more than three times the amount of a fine.

    48th article Sentinel units to fraud, and forged proved material or other means cheat medical insurance fund spending of, by human resources and social security sector ordered returned cheat of medical insurance fund, at cheat amount twice times above five times times following of fine, and and medical insurance handling institutions lifted service agreement; directly is responsible for of competent personnel and other directly responsibility personnel has practice industry qualification of, by related sector law revoked its practice industry qualification.

    49th insured persons by fraudulent or forged documents or other means of obtaining medical insurance benefits, by human resources and Social Security Department be ordered to return to defraud health insurance funds, defrauding more than twice times the amount fined not more than five times.

    50th health-insurance agencies and staff of one of the following acts, by its administrative authorities shall order rectification; losses caused to a medical insurance fund, employers or individuals shall bear liability; directly responsible in charge and other direct liable persons shall be given administrative sanctions.

    (A) fails to perform statutory duties of medical insurance;

    (B) has not been deposited on account of the health insurance fund;

    (Iii) deducted or refusing to pay health insurance benefits;

    (D) the lost or altered payment records, enjoying medical insurance records and record medical data, personal interests;

    (E) other acts that violate Medicare laws and regulations.

    51st medical insurance agency without changing the health insurance contribution base, rates, resulting in less or more health insurance, by human resources and Social Security Department be ordered to recover payment or refund should not pay health insurance premiums; directly responsible in charge and other direct liable persons shall be given administrative sanctions.

    The eighth chapter by-laws

    52nd retired cadres, army and disabled medical treatment does not change during the cultural revolution, medical expenses according to the original funding channels, there is difficulty in funds, by the people's Governments at the same level to help solve.

    Disabled revolutionary soldiers of the 53rd 1-6 provisions participating in basic medical insurance for urban workers, medical expenses that occur in urban workers ' basic medical insurance payments on the basis of the relevant provisions, by civil affairs departments to help.

    54th of municipal human resources and Social Security Department can be based on these measures, formulate related policies, submitted to the municipal people's Government for approval. 55th article of the rules take effect on July 1, 2011. The measures for the implementation of basic medical insurance for urban workers in Hohhot (14th municipal people's Government) abrogated.